Name of Outside Organization
(include address and description)C. Describe the public purpose made pursuant to the agency’s policy Identify one of the following:
California
Form
1. Agency Name
Designated Agency Contact (Name,Title)
Date Stamp
E-mail
Division, Department, or Region (If Applicable)
2. Function or Event Information
Comment:
FPPC Form 802 (4/12)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-7772)
802
(Month, Day, Year)
For Of cial Use Only
Area Code/Phone Number
Date of Original Filing:
A Public Document
Amendment(Must provide explanation in Part 3.)
Was ticket distribution made at the behest
of agency of cial?
Ticket(s)/Pass(es) provided by agency?
Event Description
Face Value of Each Ticket/Pass $
Date(s) / / / /
Name of Agency, Department or UnitNumber of
Ticket(s)/
Pass(es)
Number of
Ticket(s)/
Pass(es)
Number of
Ticket(s)/
Pass(es)
Of cial’s Name (Last, First)
If no:
Describe the public purpose made pursuant to the agency’s policy Agency Report of:
Ceremonial Role Events and Ticket/Pass Distributions
3. Recipients
Yes No
YesNo
Name of Individual
(Last, First)
Use Section A to identify the agency’s department or unit. Use Section B to identify an individual. Use Section C to identify an outside organization.
Does the agency have a ticket policy?Yes No
Provide Title/Explanation
A.
B.
If yes:
Name of Source
Ceremonial Role
Ceremonial Role
Other
Other
Income
Income
If checking “Ceremonial Role” or “Other” describe below:
If checking “Ceremonial Role” or “Other” describe below:
4. Veri cation
I have read and understand FPPC Regulations 18944.1 and 18942. I have veri ed that the distribution set forth above, is in accordance with the requirements.
Signature of Agency Head or Designee Print Name Title (Month, Day, Year) Name of Outside Organization
(include address and description)C. Describe the public purpose made pursuant to the agency’s policy Identify one of the following:
California
Form
1. Agency Name
Designated Agency Contact (Name,Title)
Date Stamp
E-mail
Division, Department, or Region (If Applicable)
2. Function or Event Information
Comment:
FPPC Form 802 (4/12)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-7772)
802
(Month, Day, Year)
For Of cial Use Only
Area Code/Phone Number
Date of Original Filing:
A Public Document
Amendment(Must provide explanation in Part 3.)
Was ticket distribution made at the behest
of agency of cial?
Ticket(s)/Pass(es) provided by agency?
Event Description
Face Value of Each Ticket/Pass $
Date(s) / / / /
Name of Agency, Department or UnitNumber of
Ticket(s)/
Pass(es)
Number of
Ticket(s)/
Pass(es)
Number of
Ticket(s)/
Pass(es)
Of cial’s Name (Last, First)
If no:
Describe the public purpose made pursuant to the agency’s policy Agency Report of:
Ceremonial Role Events and Ticket/Pass Distributions
3. Recipients
Yes No
YesNo
Name of Individual
(Last, First)
Use Section A to identify the agency’s department or unit. Use Section B to identify an individual. Use Section C to identify an outside organization.
Does the agency have a ticket policy?Yes No
Provide Title/Explanation
A.
B.
If yes:
Name of Source
Ceremonial Role
Ceremonial Role
Other
Other
Income
Income
If checking “Ceremonial Role” or “Other” describe below:
If checking “Ceremonial Role” or “Other” describe below:
4. Veri cation
I have read and understand FPPC Regulations 18944.1 and 18942. I have veri ed that the distribution set forth above, is in accordance with the requirements.
Signature of Agency Head or Designee Print Name Title (Month, Day, Year)